Treatment Options

Rev. A

Unlike other cancers, there are many treatment options for PC, and every treatment has its unique side effects.

Index:

Topic                                                                                                                Paragraph

Radiation 2.1
Radiation- Brachytherapy (seeds) 2.1A
Photon External Beam Radiation 2.2A
Proton External Beam Radiation 2.2 B
Long-Term Benefit same for both Radiation types 2.2C
Expensive Proton no better than Photon Radiation 2.2D
Just as many side effects 2.2E
Protons Killing Cancer and Our Budget 2.2F
Cyberknife 2.2G
Intensity Modulated Radiation Therapy 2.2H
Adjuvant Radiation Treatment 2.2J
Surgery 2.6
Standard Open Surgery 2.6A
Laporascopic, and Robotic Laporascopic 2.6B
Robotic Laporascopic Comments 2.6C
Robotic Surgery 2.6D
Hospitals mislead patients 2.6E
Dr. Patrick Walsh 2.6F
Robotic surgery may wreck the patients’ quality of life 2.6G
Robotic Surgery System is eating their Lunch 2.6H
Robotic surgery increased side effects 2.6J
Similar quality-of-life after robotic and open surgery 2.6K
Skill of Surgeon is Vital 2.6L
Cryotherapy 2.7
Hormones and Chemotherapy 2.8
Anti-Deprivation Therapy 2.9
Watchfull Waiting/Active Surveilance 2.10
More Treatment Options 2.11
Important Treatment Options Considerations 3.0
Stan’s Comments 4.0
Conclusions 5.0
References 6.0

 


2.1 Radiation:

– External Beam Radiation
– Brachytherapy (seeds)
– A combination of both External Beam Radiation  & Brachytherapy
– Photon Beam or Proton Beam
– Cyberknife
-Intensity Modulated Radiation Therapy (IMRT)


Radiation
2.1A Radiation- Brachytherapy (seeds)
Radiation- Brachytherapy (seeds) is used when the radiation oncologist suspects that the cancer is contained within the prostate, and not at the very outer edges. The treatment is done in one treatment. This is not used for men with large (about 60 grams or more) prostates. It may be used in conjunction with external beam radiation (EBR) to minimize the risk of damaging the rectum during EBR. This procedure is done in one day.


2.2A Photon External Beam Radiation
Photon External Beam Radiation, (EBR), will radiate the prostate and the fatty tissue surrounding the prostate, the Fossa.  This radiation, may be used as salvage treatment if there is a recurrence after surgery. EBR treatment usually requires a consecutive a seven or eight week period. This is not recommended for men with proctitis or colitis. Photon radiation uses X-ray beam radiation.


2.2B-Proton External Beam Radiation
Proton Beam therapy has theoretical advantages: It allows doctors to precisely target radiation to reach a certain depth in the body, which can reduce exposure and possibly mitigate side effects. This occurs because the beam does not continue through the body radiating everything in its path
However, there is little consensus on whether that translates to better care, except in a handful of rare cancers, including pediatric cancers of the brain and nervous system or cancers in delicate areas such as the eye.
But thus far, studies of proton therapy in prostate cancer – far more common than those rare cancers – have had limitations and provided mixed results. And it costs significantly more: around $48,000, or double that of standard radiation therapy, according to a 2008 report from the Institute for Clinical and Economic Review.
The American Society for Radiation Oncology’s emerging technology committee published a review earlier this year that said proton beam therapy was effective in treating prostate cancer, but found no evidence it was better than standard radiation therapy.
A study published in the Journal of the American Medical Association found a suggestion that, contrary to popular belief that it would cause fewer side effects, proton therapy caused more gastrointestinal problems than the most commonly used radiation therapy. (R575)


2.2C Long-Term Benefit same for both Radiation types.
The Wall Street Journal, December 14, 2012.  In a finding likely to add fuel to the debate over treatments for prostate cancer, proton-beam therapy provided no long-term benefit over traditional radiation despite far higher costs, according to a study of 30,000 Medicare beneficiaries published Thursday in the Journal of the National Cancer Institute. A Proton radiotherapy Facility typically costs about $180 million.
Critics long have cited proton-beam therapy as a costly new technology with no proven advantage. Medicare pays over $32,000 per patient for proton therapy, compared with under $19,000 for radiation, according to the study.
Side effects of radiation can include incontinence and impotence, so researchers have sought potentially less-damaging therapies.
Proton-beam therapy has been the subject of heated debate among urologists, radiation oncologists and health-care cost analysts. The therapy isn’t considered more effective than standard radiation, or surgery, at stopping the cancer. And the patient experience is about the same as with standard radiation: Patients typically have daily treatments, Monday through Friday, for approximately eight weeks. Each treatment is painless, and lasts about five minutes. The main debate has been over side effects. (Ref; R695)


2.2D-Expensive Proton Beam Therapy No Better Than Traditional Treatment For Prostate Cancer:
Another study published the week of12/28/2012, in the Journal of the National Cancer Institute has found that the expensive proton beam therapy,  prostate cancer radiation treatment provided no long-term benefit over traditional radiation. It is said to target tumors more precisely than traditional methods. However the method has been found to produce no fewer side effects than much cheaper traditional radiation therapy, and is also no better.
While advocates for proton therapy argue that the treatment blasts radiation directly into the tumor therefore avoiding any side effects, researchers found otherwise. The more common “intensity-modulated” radiotherapy (IMRT) exposes some healthy tissue to radiation and has been known to increase the number of side effects. And after one year of research, the study team found the new method also produces the same number of side effects as the traditional IMRT.
The new proton therapy method is not only expensive to the patient (costing Medicare $32,000 per patient compared to $19,000 for the traditional methods), but the cost for building the system is $125 million and up.


2.2EJust as many side effects.
On December 27, 2012 Reuters Health reported that the proton beam therapy has just as many side effects as a more common and cheaper radiation method, according to a new study. In terms of side effects, “In the long term, there’s really no difference in outcomes between proton radiation and IMRT for men with prostate cancer,” said lead author Dr. James Yu, a radiation oncologist at Yale University School of Medicine in New Haven, Connecticut.  (Ref R699)


2.2F Protons Killing Cancer and Our Budget “said Paul Levy, former president and CEO of the BIDMC. There’s an exorbitant price to pay for this pride, he wrote. Increasingly, the proton beam is being used to treat cancers that would ordinarily be treated with other, less expensive technology, he says. This, unfortunately, is contributing to a rise in health care costs Levy worries that a shift to more expensive treatments is creating a “medical arms race in America.” (R346)


2.2G Cyberknife.
The Cyberknife System helps lessen the risk of harming healthy tissue or cells that surround areas to be treated by allowing surgeons more flexibility in targeting a specific site. For prostate cancer, CyberKnife treatment is typically performed on an outpatient basis over one to five days in 30- to 90-minute sessions.


2.2 H-Intensity Modulated Radiation Therapy.
Intensity Modulated Radiation Therapy (IMRT) is when the radiation beam can deliver variable amounts of radiation to specific areas of the prostate. The radiation intensity can be increased where the cancer is assumed to be located.
After six months, about 10 percent of the IMRT-treated patients, and six percent of the proton therapy patients, had side effects including incontinence, burning sensations during urination or difficulty getting an erection. However, the difference disappeared a year after treatment, when an equal number of patients (one in five) suffered side effects regardless of method used.(Ref: R699A).


2.2J-Adjuvant Radiation Treatment
Adjuvant  Radiation Treatment given within six (6) Months of a radical prostatectomy in which the cancer has spread beyond the prostate capsule can make an enormous difference in the recurrence rate, said  Dr John Libertino, MD chairman of the Department of Urology at Lahey Clinic. This study was reported at the 2001 American Association Meeting (Ref Stan’s Articles A149, and A-199, and reported in the Boston Herald, 6/4/2001).

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Surgery

 Surgery:
– Standard open surgery
– Laprascopic
– Robotic Laprascopic


2.6A– Standard Open Surgery usually requires a two to four day hospital stay.

 

2.6B-Laporascopic, and Robotic Laporascopic
Laporascopic Surgery is when the urologist (Surgeon), manipulates the instruments. Robotic Laporascopic Surgery is when the urologist controls the computer, which manipulates the instruments with the patient being 20 feet distance from the doctor. Another doctor is nearby to do standard surgery, in the event the robotic system malfunctions.The hospital stay for these surgeries is usually one or two days.
As of now, there is no known difference in outcome between the Standard Open and the two  Laporascopic surgery methods. The doctors who do one of these procedures will tell you that their method is better / superior than the other methods.(A 336) ( Ref 57) Surgery is usually not a good option for a man who is frail, or has limited life expectancy.


2.6C-Robotic Laporascopic Comments
Opposition to Laprascopic surgery:
There is a body of doctors who that feels very strongly that Robotic Laparascopic Surgery and Proton Beam Radiation are not better for treating prostate cancer, and only increase the cost of treatment. Here are some of their comments:


2.6D
Robotic Surgery:
Anyone who is considering Robotic surgery, should read reference R429 that has inputs from Dr. Bert Vorstman, MD. It is a “must article”by an urologist. Portions are included herein.
Don’t believe hype about robot prostatectomy:
Men considering robotic surgery for prostate cancer shouldn’t trust the rosy ads promoting the expensive technology over low-tech surgery.
A study, published in 2012, in the Journal of Clinical Oncology, is based on 600 prostate cancer patients.
Nearly nine out of 10 men had a moderate or big problem with sexual functioning 14 months after their surgery, Dr. Michael Barry of Massachusetts General Hospital in Boston and colleagues found. About a third said they had incontinence trouble after their surgery. Complaints about sexual problems and urinary leakage were equally common after both the robotic and open surgery procedure.
“I wasn’t surprised at all,” said Dr. Otis Brawley, chief medical officer of the American Cancer Society, who wasn’t involved in the study. “Unfortunately, robotic prostatectomy – like many things in prostate cancer – has gotten a lot more hype than it should.”
There is no good evidence to show Robotic prostatectomy is better than traditional prostate removal. It is, however, much more costly, adding some $2,000 in hospital costs per procedure.


2.6E-Hospitals mislead patients about robotic surgery.
Robotic surgery is often touted as the latest and greatest breakthrough in medical technology, but a new study suggests that many hospitals in the United States mislead patients about its benefits. Johns Hopkins researchers found that 40% of hospital Web sites promote robot-assisted surgery, even though little evidence shows it’s better than conventional methods.
The study, published in the Journal for Health Care Quality, evaluated 400 randomly selected hospital Web sites. Researchers looked at the placement of information about robot-assisted surgery on the sites, claims about its risks and benefits, and the use of images or text provided by the robot’s manufacturer.
About forty percent of the Web sites described the availability and mechanics of robotic surgery. Of these, 37% mentioned robot-assisted surgery on the home page and 66% cited information about the procedure within one click of the home page. Nearly three-quarters of the sites used industry-provided marketing materials or linked to the manufacturer’s Web site. When describing robotic surgery, nearly all of the hospital web sites claimed clinical superiority to other surgical methods; one-third also reported improved cancer control. None of the sites noted any risks.
Dr. Marty Makary, the study’s leader, questions how hospitals arrived at their claims about the robot’s benefits and voices concern about potential conflict-of-interest, given that robotic procedures typically cost more than traditional ones.
“The public regards a hospital’s official Web site as an authoritative source of medical information,” he said in a statement issued by Johns Hopkins. “Hospitals need to be more conscientious of their role as trusted medical advisers and ensure that information provided on their Web sites represents the best available evidence.”  Published June 10, 2011. ( Ref R465   Harvard Prostate Pointers)


2.6F-
Dr. Patrick Walsh.
Dr. Patrick Walsh who pioneered nerve sparing prostatectomy at Johns Hopkins, cautions against robotic surgery for this reason. He worries that without feeling the prostate, the robotic surgeon cannot fully appreciate disease extension beyond the gland which risks leaving cancer behind. Indeed, a recent review of robotic prostatectomy found twice as many surgical failures compared to the standard operation. (Ref: R624, 2012)


2.6G-Robotic Surgery may wreck Quality of Life:
The outrage, according to urologist Dr. Bert Vorstman, is that, many times, the Robotic surgeries wreck the patients’ quality of life and are simply unnecessary, resulting in incontinence, impotence and struggling with intimacy and other quality of life issues that are more serious than their slow-growing cancer. Many patients, wowed by fancy marketing campaigns and driven by an urgency to “fix” their disease, mistakenly think that “high-tech equipment equals high-tech results,” Vorstman says. So they go along with a radical recommendation to cut their prostate out when less invasive treatments, even no treatment at all, that is, “watchful waiting” — are often the better course. National Institutes of Health “It just amazes me that so many patients are OK with whatever their doctor says they should do. It’s astounding.”, he said.  Vorstman, a former surgeon researcher is on a personal campaign to educate the public, and to expose what he calls an ego-driven, profit-centered medical industry that is minimizing the risk of robotic surgical treatment at the peril of the patients it’s supposed to serve. Dr. Bert Vorstman, whose expertise in prostate cancer diagnosis and treatment, is challenging the validity of curative life extension claims promoted by manufacturers and surgeons employing radical prostate surgery/robotics. He said, “some men claim no complications following radical surgery/robotics. However, in addition to shortening of the penis and a high rate of residual cancer in men after radical surgery/robotics, many men are often too embarrassed to admit to post operative urinary leakage and issues of a sexual nature. These quality of life issues clearly underscore the fact that surgery/robotics is no panacea for prostate cancer treatment. Surgeons as well as marketers continue to promote robotic technology for radical prostatectomy by a creative spin, using such terms as “advanced”, “minimally invasive”, and “superior outcomes.” The sad truth is that prostate cancer surgery is solely responsible for the worldwide increase in urinary incontinence and impotence but without the benefit of curative life extension.
“The term “Gold Standard” for surgery is a very unfortunate, self-anointed, self-serving term, which implies established and proven benefits, when the truth is far from it.  Surgery is simply the oldest treatment modality for prostate cancer, without benefit of rigorous scientific evaluation for risk or reward,  and therefore, is deemed as the “Gold Standard. There is no other high-risk surgical technology for prostate cancer to be so approved “, he said.
Some doctors’ willingness to put ego and profits ahead of what’s best for the patient , Vorstman says, goes against everything they’re taught, especially “do no harm.” (R528)


2.6H
-Robotic Surgery System is eating their Lunch:
The president of a major Harvard teaching hospital resisted purchasing the million dollar robotic surgery system for years because he knew it was not better and only more expensive for the patients.
He finally yielded and purchased it because the other area hospitals were getting the patients because they advertised they had the latest and greatest equipment and techniques. They were “eating his lunch”.


2.6J-Robotic surgery increased side effects:  
A 2009 study found more incidents of incontinence and erectile dysfunction in men who had robotic surgery when compared with those who had the traditional procedure. “The take-home message for men is they need to dig deeper than simply the message they might be getting from planted stories from device manufacturers or radio ads or billboards,” Dr. Jim Hu, a robotic surgeon formerly from the  Brigham and Women’s Hospital in Boston and the study’s lead author, told USA Today.(Ref R429 and R528)


2.6K-Similar quality-of-life outcomes after robotic and open surgery to treat prostate cancer:
 
A Cleveland Clinic study of more than 300 prostate cancer patients shows that urinary continence and sexual function scores are similar after robotic-assisted laparoscopic radical prostatectomy and open radical prostatectomy.
“These operations were performed by high-volume experienced surgeons in their field, which may explain the absence of significant differences in the outcomes,” said Andrew Stephenson, M.D., a urologist. “This suggests that the experience and technique of the individual surgeon play the greatest role in achieving a successful outcome rather than the surgical approach that is employed.” 12/3/1012 (R681)


2.6L-Skill of Surgeon is Vital:
When robotic surgery is the treatment choice, the primary consideration should be the skill, and experience of the surgeon. (NY Times, October 13, 2009)

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2.7-Cryotherapy:

The freezing of the prostate by having very cold probes inserted into the prostate. Cryotherapy, the freezing treatment, is not done much in New England, but is done frequently in other parts of the country. This method uses probes inserted into the prostate with extremely cold chemicals inside them to freeze the surrounding prostate tissue. This treatment may be repeated if a recurrence occurs. This treatment has also been done as Focal Therapy, to minimize some side effects. It is similar to a lumpectomy in Breast cancer, in that the freezing is done in selective areas of the prostate where the cancer is thought to be. This avoids removing or treating the entire prostate. See Comment section about this


2.7A-Focal Therapy:
The treating specific areas of the prostate where the cancer is believed to exist.(Lumpectomy)  (R667)
Focal Therapy treatment for prostate cancer can be accomplished using Cryotherapy, HIFU, lasers or photodynamic approaches, but Cryotherapy is mainly used in this country.

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2.8-Hormones and Chemotherapy.
Hormone injections are often given for a six month period when external beam radiation is being administered. Adding hormone therapy to radiation therapy has been shown to increase overall survival for men with intermediate- and high-risk prostate cancer, and is used to treat advanced cases of PC.  Chemotherapy is often used in advanced cases, and frequently in conjunction with Hormones. Various chemo drugs may be used together, as part of an advanced treatment protocol and clinical trial. Medical Oncologists usually are involved with these treatment.

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2.9-Androgen Deprivation Therapy.
Androgen Deprivation Therapy (ADT) is treatment with specific drugs to lower the testosterone  level in the body to stop or slow the progression of the cancer. It may be used alone or in conjunction with radiation. It is not considered a curative treatment, but rather a first  treatment before a another treatment is used.
It is reported that adding hormone therapy may reduce overall survival in men with pre-existing heart conditions, even if they have high-risk prostate cancer according to a study published online in advance of print in the International Journal of Radiation Oncology•Biology•Physics, the official scientific journal of ASTRO.  July 26, 2011(R388).

Early hormonal therapy hikes death rate in men with recurrent low-risk prostate cancer.
This article discusses the danger of a recurrence, and perhaps death if the PSA does not decrease to a low level after treatment.
It was  written by Dr. Marc Garnick, MD, a Medical Oncologist at the BIDMC, who is Editor in Chief of the “2016 Annual Report on Prostate Diseases”, which is published by the Harvard Medical School. It is on page 7

Here is a link to the article.

Early ADT hikes deaths in men with recurrent low risk prostate cancer

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2.10-Watchful Waiting, also called Active Surveillance, also known as Delayed Treatment for a few, or many years, and perhaps forever.  WW requires having a PSA blood test about every 4 to 6 months, and one or two repeat a biopsies after about 1.5 and 3 years. Unfortunately, It is not done often enough, because doctors prefer to treat. See the section on Watchful Waiting.
WW may be stopped at any time to start active treatment if desired or needed

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More Treatment Options:
2.11- High Intensity Focused Ultrasound (HIFU): High-Intensity Focused Ultrasound (HIFU), is a precise medical procedure that applies high-intensity focused sonic energy to locally heat and destroy diseased or damaged tissue through ablation; in this case to the prostate. HIFU is a hyper-thermia therapy, a class of clinical therapies that use temperature to treat diseases. It is a minimally invasive or non-invasive method to direct acoustic energy into the body. Anesthesia is not required, but is generally recommended.

This is an outpatient procedure that usually lasts 1–3 hours. Results show that it greatly reduces some of the side effects common with other treatments for prostate cancer, because, it is claimed, the sphincter and bladder neck are identified and avoided.

After 12 years, this procedure is now available in the United States as well as Mexico, Canada, and Europe (see article below).

HIFU to treat prostate cancer approved R1142
Non-Invasive Robotic Surgery Destroys Prostate Cancer Tumors

LOS ANGELES           December 10, 2015    Elizabeth Lee

Prostate cancer is the most common cancer in American men and is the fifth-leading cause of cancer death in men globally.

While death rates for prostate cancer have been decreasing in most developed countries, mortality rates are rising in some European and Asian countries such as South Korea, China and Russia. A non-invasive way of removing prostate cancer tumors is now available in the United States with the help of robotic technology.

The University of Southern California is the first academic medical center in the U.S. to perform this type of procedure.

Brett Lindsay knows he made history when he underwent a procedure known as robotic high intensity focused ultrasound, or HIFU.

“I was excited about the new procedure because it was more or less non-invasive. The recovery time was a lot quicker — did not have to remove the prostate,” Lindsay said.

The U.S. Food and Drug Administration recently approved the procedure even though it’s been used in other countries to treat prostate cancer for about 10 years. Traditional prostate cancer treatments include either removing the entire gland or radiation, which will affect the quality of life for patients even if the cancer is removed, said Inderbir Gill, lead urologist at the University of Southern California Institute of Urology at Keck Medicine of USC.

“The nerves that are lying right next to the prostate that are responsible for erections, the sphincter that’s lying right next to the prostate that is responsible for urinary continence, they get compromised. So, yes, you take care of the cancer, but you significantly impact the person’s quality of life,” Gill said.

Only cancer is targeted

With HIFU, only the cancer is identified, targeted and destroyed. The HIFU procedure is an outpatient procedure, said Robert Barnett of SonaCare Medical, one of the manufacturers of the technology.

“Here we’re taking ultrasound energy off of a concave or bowl-like surface and bringing that to a focal point, and at that point we have tremendous heat generated and we can destroy tissue,” Barnett said.

HIFU devices are used in Western Europe, Latin America and some Asian countries, but not so much in developing countries.

“I think in the Third World if you will, in developing countries, it’s a financial thing. Those countries certainly don’t have the resources to commit to health care. Their focus is more on preventing infectious disease,” Barnett said.

But he said that, looking at the global cost of treating prostate cancer, HIFU technology is less costly than radiation and it can easily be implemented in an unsophisticated medical setting.

Gill said having the HIFU procedure at an academic medical center will allow them to further research the outcomes of HIFU procedures, minimize any side effects and advance the technology.

The objective is “to figure out what molecular and genetic markers predict HIFU success, HIFU failure. Which patients are the best candidates for it? How do we not overtreat cancer? How do we not undertreat cancer?” Gill said.
Brett Lindsay said he’ll relax at home for a few days before going on a business trip in less than a week.
A number of people have gone to Mexico, Canada, and Europe to have this treatment because the FDA has not approved its use in the USA.  Some people claim that because it would be a much less expensive procedure, the American medical system is blocking the approval of HIFU.

2.12- Chemotherapy uses one or a combination of a few drugs
2.13– A combination of ADT & Chemotherapy
2.14- Assorted Options
External beam radiation is frequently given after surgery has failed (Salvage Therapy).
Advanced treatment is frequently used after Surgery and / or radiation treatments have failed. For example Salvage High Intensity Focused Ultrasound would be used after a previous treatment has not cured the patient. (R660)

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3.0 Important Treatment Option Considerations
3.1 Treatment Comparisons
3.2 Hospitals Influence treatment Choices
3.3 Self Referrals
3.4 Know the location of your cancer

3.1A-Treatment Comparisons.
Researchers at the Massachusetts General Hospital’s Institute for Technology Assessment, examined the published evidence on different approaches being used to manage low-risk prostate cancer, and concluded that when it comes to the treatment of low-risk prostate cancer, a new comparative effectiveness study has concluded that the various approaches—including active surveillance, surgery, and radiation therapy—result in similar overall survival and tumor recurrence rates. However, compared with the immediate treatment options, active surveillance yields both a comparable net health benefit and more quality-adjusted life years for men age 65 and older, according to the economic model used in this study. (Ref: R128)

3.1B-A very experienced medical oncologist at the BIDMC, Dr.Glenn Bubley, has said, “ in 90 percent of low grade prostate cancer cases, the outcome is the same whether surgery or radiation is selected– pick the side effects and go with that treatment”
This was also stated in the January 2003 issue of the US TOO HotSheets.
There is no one gold treatment standard – huge improvements in radiation have made surgery and radiation equal. A doctor usually stresses his specialty. (Ref 31)
Severe side effect complications can occur with a combination of seeds and EBR (Ref 32).
To help men consider all their options, refer to a published  article that I wrote called, “Interviews with your Prostate Cancer Doctors”  This contains questions to ask the three PC  specialists. See Documents of Interest Segment.

3.2-Hospitals Influence treatment Choices
The treatment choice a man makes was often influenced by the hospital they visited:
In this randomized controlled trial, patients were randomized to a group which only discussed their treatment with their specialist or received additional information from a researcher. 240 patients with localized prostate cancer were enrolled from three separate hospitals. They were selected to be eligible for both prostatectomy and external beam radiotherapy.
RESULTS: Treatment choice was affected by the researcher and by the hospital of intake.
Stan’s Comment: Should the doctors not have recommended what was best for the patient?

Usually when a man is diagnosed with PC he is with a urologist. If he does not consult with other PC specialists, he will invariably select the treatment the urologist recommends. However, when the man is seen by the other specialists, there is a much greater chance he will make a more educated decision, based on what he has heard from all parties. In reality most men usually will select surgery, but also in reality, he has not been informed about watchful waiting. (Ref 618)..

3.3– Self Referrals or where to be treated ?
Aside from the actual treatment perhaps the reader should be aware of where the treatment is actually done.  Some doctors form an association or corporation and purchase the radiation, X-rays and other medical treatment equipment, and recommend having the treatment done there. (Ref: Google Alert 3/1/2011 called Self Referral Centers. Ref: R709)
The reason given for using this facility is often, that you can get treated sooner than if it is done in the hospital. This has disadvantages..You have nothing to gain in the private facility, and much to loose. (Ref: Wall St Journal Dec.8-2010  R345 titled “Uologists Recommendations”)
If you are going to have a medical procedure, have it done at the hospital, not at a privately owned facility. Ref: WSJ Dec. 12, 2010
There are a few good reasons to do this.
!- Should a problem arise, the hospital will have the staff right there and then to try to rectify it.
2- The Hospital probably has more insurance coverage than the privately owned facility.
3- Support your hospital. If a private facility fails financially, it only affects the owners. When a hospital fails financially, it affects you and the entire community, and puts a strain on other nearby hospitals.
4- The chances are probably high that the doctor recommending the private facility, has a vested financial interest. It may not be as good for you, the patient.
5-Do not believe any story, that “ there is less waiting time to go to the private facility” I have found that if you have a critical /emergency condition, the hospital will give you priority, and is a much better place to be.
6-The chances are the private facility is costlier, but even if it is the same cost, the above factors should be considered.
7- In summation, let the buyer beware.

As of now, there is no known difference in outcome between the Standard Open and the two Laprascopic surgery methods. The doctors who do any of these procedures will tell you that their method is better / superior than the other methods. (A 336) ( Ref 57) Surgery is usually not a good option for a man who is frail, or has limited life expectancy.

3.4- You should know exactly where your cancer was found in your prostate as significant cancer at the base or apex can mean that the cancer is no longer confined to the prostate and that radiation would be a reasonable treatment option.  (Ref: R528 called PC Surgery Myths & Damn Lies)    Return to Index


4.0 Stan’s Comments
4.1 The Surgeon’s skill is very vital                             
4.2 Treatment Based on EmotionsThe Surgeon’s skill is very vital4.3 Important Treatment Considerations
4.4 Second Opinions, Why to have them
4.5 Focal Therapy


4.1 The Surgeon’s skill is very vital.
When Robotic surgery is the treatment choice it is true the doctor needs to do a minimum number of procedures to become proficient, but that is only part of the requirement. What is of greater value is the innate skill of the doctor.
A baseball example will illustrate this point.
Most people know the names Joe DiMaggio, Babe Ruth, Lou Gehrig, as outstanding in their profession. The other baseball players did not practice less, and they were at bat just as often, but never achieved the same greatness. Why?  The answer is the innate skill these men were born with. This is also what made Picasso, and Rembrandt great.
A New York Urologist boasts about the thousands of surgeries he has done. What this proves is that he has had a high income, but it tells us nothing about his skills. He may be great, but one certainly cannot tell by how busy he is. Certainly, not in the prostate cancer field.
The moral of the story is to verify how good a doctor is by speaking to dozens of his patients, and then asking them have they spoken to other men treated by the same doctor they are considering selecting.

4.2 Treatment selections based on emotions
Doctors report that many men choose their treatment based on emotions, not the facts, i.e. “cut it out” and “get rid of.” This, in my opinion, is a blunder. Do not rush making your treatment choice. Visit the three PC specialists, the Urologist, Radiation Oncologist, and Medical Oncologist, one at a time, to concentrate on what each doctor is saying, and ask about Watchful Waiting. Have the WW Criteria with you, and discuss it point by point.
Treatment of low-risk cases has no survival benefit because 50 percent don’t need treatment. As an example, if you had a splinter in a finger, and the finger or hand was amputated, the statistics would say you survived, but did the treatment help and was it necessary? This is how the Prostrate Cancer Medical Profession has such high success rates. The men who did not need, but received treatment, and survived are part of the successful statistics !!
Some doctors say that there is “no proof that treatment extends life.  This is not true for advanced case.” Some men like me have a very aggressive PC which has not yet advanced. Treating this person may cure or postpone death for many years.

4.3 A word of caution
The first doctor a man usually visits after he has been diagnosed with PC is the urologist, who frequently is the person who did the biopsy. If this doctor says he can treat you, you should never agree to be treated until you have visited all three PC specialists. It is imperative you consult with all three specialists. No business person likes to loose a customer to someone else, and medicine is a business——-a huge business.Even if you are told your cancer is in the very early stages, and there is no reason to go further, you must visit the Medical Oncologist, because you may not need treatment now, and perhaps not for a long time, or never. Your outcome will be most likely be the same, whether treated now, later, or never, but your Quality of life will be drastically different.After your biopsy, if your urologist tells you not to delay, and to make a decision very soon because it is urgent, you should immediately make an appointment with an experienced medical oncologist. If your cancer is so aggressive, or so advanced, it is imperative you consult with the medical oncologist.  Otherwise consult with all three specialists.Keep an open mind, and do not be swayed by either your friends recommending the treatment they had, or by any doctors recommending their specialty. Review the questions in the “Interviews With Your Prostate Cancer Doctors” in the Documents of Interest Segment, and visit all three  PC specialists. Have a family discussion, before deciding on any treatment or WW.

4.4 Get a Second Opinion
Every doctor says that a second opinion is a wise move to make, but most doctors are unhappy when you obtain one. Having a second opinion does not necessarily mean that you do not like the doctor or his recommendation. Rather, it signifies that you are cautious and want to be sure you are making the best choice for your specific situation. It is your life and quality of life that is your concern. Should the second opinion be different from the first, there is nothing wrong with obtaining a third opinion. Visiting a  doctor with a different specialty is not a second opinion. A second opinion means consulting with another doctor with the same specialty, and preferably from another medical institution. Get as objective an opinion as possible, preferably from someone who will not be treating you..
Second opinions of the pathology report may result in a different treatment in some cases, and should also be considered. For example if a Gleason Score of 4+3=7, is determined to be 3+3=6, Watchful Waiting is now an option for you. The reverse is also possible.
It has always been my opinion that a medical oncologist has the most objective opinion for someone with a low or medium grade cancer, because he will not be treating you. I believe it is very difficult for a surgeon or radiation oncologist to be as objective, because they benefit from treating you. If you have an advanced case, the medical Oncologist is a must.

4.5-Focal Therapy According to most doctors performing Focal Therapy (Lumpectomy), they will not find and treat all the cancerous locations within the prostate, in that when a prostate is removed, the cancer is found in other locations within the prostate. The doctors who advocate this Focal Treatment, say this is not a problem because the Cryotherapy can be repeated when the PSA rises, and new “Hot Spots” are located, and treated. This refers to paragraph 2.3 ,Cryotherapy.

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5.0 Conclusions
5.1 You are free to select any treatment you desire, but please consider these points:

  • Do not rush to make a treatment decision.
  • Visit all three prostate cancer specialists
  • Get second opinions not only from the doctors, but of your pathology report. This will verify your condition
  • Do not select a specific treatment because someone you know had it and is doing well. Your case is rarely the same as his
  • Do not believe most of the literature in the newspapers, magazines and on the internet. Most are written by doctors or specialty groups who have their own biases. Recognized Journals are more reliable, but if the journal is published by a specific medical specialty, there is likely a bias there too
  • There is nothing like an independent prostate cancer support group that has members regardless of where they were treated, who can freely contact and speak to each other.
    Stan
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References
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R128-National cancer Institute  |January 12, 2010, Volume 7 / Number 1J
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R345Wall St Journal, Dec   2010  Globe Staff / May 14, 2012
R388-the International Journal of Radiation Oncology•Biology•Physics, the official scientific journal of ASTRO
R429-South Florida Sun-Sentinel  September 11, 2011
R465 Reference: J Urol. 2011 Nov;186(5):1862-7. PubMed Abstract  PMID: 21944095
R528-RELEASE  Jan. 31, 2012, Market watch
R575- Globe Staff / May 14, 2012
R624-The Union, Western Nevada County, CA
R660-Reference: Radiotherapy  Oncol. 2012 Oct 12
R667 Focal Therapy, Frequently Asked Questions-: Call 646-754-2400 Smilow Comprehensive Prostate Cancer Center | 135 East 31st Street, 2nd floor | New York, NY 10016
R681R CLEVELAND, OH USA (Press Release) – December 3, 2012 -Cleveland Clinic
R695-The Wall Street Journal   Published December 14, 2012R699A
R699A Journal of the National Cancer Institute
R699- http://bit.ly/V6PkLT Journal of the National Cancer Institute, online December 14, 2012.
R709-16 January 2013  Business Day Live

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